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Upper and Midfacial Rejuvenation in the Non-Caucasian Face

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Upper and Midfacial Rejuvenation in the Non-Caucasian Face Author's personal copy Upper and Midfacial Rejuvenation in the Non-Caucasian Face Rami K. Batniji, MDa,b,*, Stephen W. Perkins, MDc,d KEYWORDS Endoscopic brow lift Botulinum toxin Filler augmentation Midface lift Lower lid blepharoplasty Upper blepharoplasty In the nineteenth century, Johann Friedrich Blu- location of the eyebrow apex in Asian and white menbach popularized the term ‘‘Caucasian’’ to women. Their findings suggested that neither the describe a distinct group of people from the Cau- ethnicity of the models nor the ethnicity of the casus region with specific craniofacial features. volunteers who analyzed the eyebrow position Although the Caucasus region lies between had a significant role in determining the ideal Europe and Asia and includes Russia, Georgia, eyebrow position. A survey of plastic surgeons Armenia, Azerbaijan, and Iran, the term Caucasian and cosmetologists regarding eyebrow shape in has since been used to describe those individuals women by Freund and Nolan4 found that a medial of European origin. Although age-related changes eyebrow at the level of the supraorbital rim was have some similarities between Caucasians and ideal and that brow lifting techniques tend to non-Caucasians, there are also some distinct elevate the medial eyebrow above this level. differences. In this paper, the authors discuss Increasing eyebrow height with age has been treatment options, surgical and nonsurgical, for previously reported, and this phenomenon has rejuvenation of the upper face and midface, been attributed to habitually contracting the fron- including the periorbital region. For the purposes talis muscle. Therefore, an overly elevated brow of this paper, the term non-Caucasian includes may not only result in a surprised appearance African American, Middle Eastern, and Asian but also impart an aged countenance.5 ethnicities. During the evaluation of the upper eyelid, the forehead should be assessed for ptosis, as this may confound the diagnosis of upper eyelid der- matochalasis. The surgeon should evaluate the FACIAL ANALYSIS upper eyelid to rule out the contribution of blephar- The Upper Third of the Face optosis. The position of the upper eyelid should The ideal eyebrow shape was defined as an arch ideally rest at the level of the superior limbus. If where the brow apex terminates above the lateral unilateral blepharoptosis is identified, the surgeon limbus of the iris, with the medial and lateral ends must rule out blepharoptosis in the contralateral of the brow at the same horizontal level.1 This defi- eye, as Herring’s Law may apply in this situation. nition has been further refined to provide a frame- The Asian upper eyelid has several distinct work for the analysis of the upper third of the face anatomic characteristics including low, poorly and subsequent treatment options for forehead defined or absent eyelid crease, narrow palpebral rejuvenation.2 Biller and Kim3 studied the ideal fissure, and/or epicanthal fold.6 a Batniji Facial Plastic Surgery, 361 Hospital Road, Suite #329, Newport Beach, CA 92663, USA b Department of Plastic Surgery, Hoag Hospital, Newport Beach, CA, USA c Meridian Plastic Surgeons, 170 West 106th Street, Indianapolis, IN 46290, USA d Indiana University School of Medicine, Department of Otolaryngology, Indianapolis, IN, USA * Corresponding author. E-mail address: [email protected] (R.K. Batniji). Facial Plast Surg Clin N Am 18 (2010) 19–33 doi:10.1016/j.fsc.2009.11.015 1064-7406/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved. facialplastic.theclinics.com Author's personal copy 20 Batniji & Perkins of lower eyelid skin).8 In addition, the orbital septum weakens with age leading to steatoblepharon (pseu- doherniation of orbital fat).9 Orbicularis oculi muscle hypertrophy is also associated with age-related changes of the upper and lower eyelid complex.10 The tear trough is also known as the nasojugal groove and is defined as the natural depression extending inferolaterally from the medial canthus to approximately the midpupillary line.11 A hollow- ness may be present lateral to the midpupillary line and parallel to the infraorbital rim; this has been referred to by various names, including the lid/ cheek junction. Various anatomic explanations Fig. 1. The trichophytic incision is approximately 4 cm for the tear trough deformity have been provided in length and is made at the midline following the natural irregular contour of the hairline. Laterally on in the literature, including an attachment of orbital each side a 3- to 4-cm incision is made 2 cm posterior septum to arcus marginalis at the level of the to the temporal hairline recession at a location demar- orbital rim, a gap between the levator labii superio- cated by the lateral canthus and temporal line. ris alaeque nasi muscle and the orbicularis oculi muscle, and loss of facial fat in the tear trough or pseudoherniation of fat superior to the tear trough. The Lower Lid/Midface Complex The tear trough and lid/cheek junction occur infe- rior to the orbital rim and arcus marginalis. Evaluation of lower eyelid position and laxity is an essential part of the examination. The ideal position of the lower eyelid margin is at the inferior limbus.7 A TREATMENT OPTIONS snap test and lid distraction test are key compo- Brow/Forehead nents to the evaluation of lower eyelid laxity. A Nonsurgical options for brow/forehead snap test is performed by grasping the lower eyelid There are several nonsurgical options available for and pulling it away from the globe. When the eyelid is the rejuvenation of the brow/forehead, including released, the eyelid returns to its normal position neuromodulators, dermal fillers, and autologous quickly; however, in a patient with decreased lower fat grafting. For example, Lambros reported volu- eyelid tone, the eyelid returns to its normal position mizing the brow with hyaluronic acid fillers to more slowly. The lid distraction test is performed give more youthful appearance to the brow/perior- by grasping the lower eyelid with the thumb and bital region.12 index finger; movement of the lid margin greater than 10 mm demonstrates poor eyelid tone and an Surgical options and technique for brow/ eyelid tightening procedure is indicated. A Schirmer forehead test is indicated if there is concern about dry eye Many techniques for surgical rejuvenation of the syndrome. Progressive loss of elastic fibers and upper third of the face have been described in collagen organization lead to dermatochalasis the literature. Although the open technique via (loss of skin elasticity and subsequent excess laxity a coronal or trichophytic approach has been the Fig. 2. (A) The Ramirez EndoForehead parietal elevator (Snowden Pencer, Tucker, GA) is used to elevate the forehead and temporal skin in a subgaleal plane. (B) The elevation is continued approximately 5 cm posterior to the incision sites. Author's personal copy Upper and Midfacial Rejuvenation 21 Fig. 3. (A) A custom-made curved elevator is positioned into the temporal region through the lateral incision to divide the conjoint tendon. (B) Dissection of this temporal region is performed down to an area slightly superior to the zygomatic arch and lateral canthus. standard with which all other techniques have of the deep temporal fascia, and the conjoint been compared, our preferred method for surgical tendon is then divided (Fig. 3). Dissection of this rejuvenation of the brow is the endoscopic brow temporal region is performed down to an area lift. Botulinum toxin injected into the corrugator slightly superior to the zygomatic arch and lateral supercilii and procerus muscles at least 2 weeks canthus. The frontal branch of the facial nerve is before endoscopic brow lift. The combination of protected because the plane of dissection is chemical ablation of the depressor muscles with between the temporoparietal fascia and the super- botulinum toxin A and myotomy of the depressor ficial layer of the deep temporal fascia. Following muscles during the endoscopic forehead lift acts this, elevation is made in a subperiosteal plane synergistically not only to maintain the elevated down to a level of 2 cm above the supraorbital rim forehead position but also to treat the nasoglabel- (Fig. 4) and the arcus marginalis is then elevated. lar furrows. The addition of botulinum toxin may Arcus marginalis elevation is performed with the also lessen the chance of return of depressor nondominant hand functioning as a guide to the muscle function compared with myotomy or level of the supraorbital rim and the location of the myectomy alone. supraorbital foramina (Fig. 5). This elevation is per- One noticeable effect of the endoscopic brow lift formed in the region of the glabella down to the na- is an elevation of the hairline. Although this is an sion. Once the arcus marginalis is elevated, an acceptable result for most patients, persons who endoscope is used to provide visualization; and have high hairlines (greater than 5 to 6 cm) may the conjoint tendon is further divided with curved not wish to move the hairline more posterior. We endoscopic scissors (Accurate Surgical & Scien- perform a technique combining a short 3- to 4-cm tific Instruments Corp, Westbury, NY) down to the trichophytic incision with endoscopic equipment level of the sentinel vein (Fig. 6). Care is then taken to lift the forehead in patients who present with to identify and preserve the supraorbital brow ptosis and high hairlines.13 This technique includes a trichophytic incision that is approxi- mately 4 cm in length and is made at the midline following the natural irregular frontal hairline contour in a scalloped fashion. Laterally, on each side, a 3- to 4-cm vertical incision is made 2 cm posterior to the temporal hairline recession at a location demarcated by the lateral canthus and temporal line (Fig. 1). Initially, flap elevation is made in a subgaleal plane (Fig.
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